With AIDS, talk of blame is outdated

You don't hear much about AIDS in America anymore. The few new headlines are reserved for dispatches from the developing world, where the dying young still make good old-fashioned heart-wrenching copy.

But AIDS endures right here in the United States: Our outpatient clinics are bursting at the seams, and new cases show up daily. A million domestic stories are languishing untold, but they are not the operatic tragedies we have grown used to.

Instead, as illustrated by this month's report about a Florida athlete indicted on charges of willfully transmitting HIV, the virus that causes AIDS, these are nuanced and complicated fables, with morals that extend beyond the disease itself.

The athlete, Darren Chiacchia, a bronze-medal Olympic equestrian, was charged a few months ago with what is a first-degree felony in Florida: repeatedly exposing a sexual partner to HIV. Chiacchia first tested positive for the virus in 2008, and his partner reportedly tested negative when their relationship began in early 2009.

The relationship ended in rancor six months later, and the partner filed a complaint with the sheriff, claiming that Chiacchia never disclosed his infection -- that the partner found out only by discovering medical papers confirming it. It is not known whether the partner did in fact contract HIV during that time. Chiacchia's trial begins in June.

Most states enacted punitive legislation back in the hysterical old days of AIDS, a period lasting roughly from 1981, when the first reports of the syndrome were published, to 1996, when combination drug "cocktails" proved remarkably effective against HIV. Back then, transmitting the disease to an unknowing sexual partner was considered tantamount to murder.

These statutes are still on the books, but the science behind them has changed radically. People do still die of AIDS in the United States -- the death rate, after plummeting in the late 1990s, has remained constant at about 16,000 per year. But for a person infected in 2009 to die of AIDS in the future would probably require a substantial amount of bad judgment or bad luck: the medications, if properly prescribed and properly taken, appear almost infallible.

Were it a matter of science alone, all those AIDS statutes could be rescinded tomorrow. But the science was only a small part of the panic that created them. And effective treatment has not altered the rest of that potent emotional brew: the virus still sows terror, uncertainty, shame and endless complications, whether the infection is concealed or revealed.

All of us, no matter how learned, carry an eternally primitive creature in our brains. It is a small homunculus who will always react to illness -- any illness -- with anger, disbelief and a search for blame. Centuries ago we burned witches and torched infidels for poisoning our wells; diseases were the fault of our enemies (in the 15th century, syphilis was simultaneously the Italian disease in France and the French disease in Italy).

Now we think we know better, but do we really? We blame that coughing woman in the subway for our cold, the giant meat company for our food poisoning, all manner of chemicals and electromagnetic radiation for our cancers, and fast-food outlets for our diabetes and heart disease. We cannot experience illness without casting around for blame.

Yet at the same time we believe deeply in prevention. Surely if we watch our diets and get our mammograms and colonoscopies, wash our hands, take whatever vitamin is foremost in the news and eat our burgers well done, we can avert bad things. Whole generations have now grown up knowing that sensible people "play safe," with the overriding implication that if you catch a sexually transmitted disease, you have no one to blame but yourself.

And so whose fault is a new HIV infection, really? Is it mine, for giving it to you, or is it yours, for being stupid and cavalier enough to get it?

The court will eventually sort out the Florida case, where despite the particulars the matter is probably less about infection than the old lover's plaint "I trusted you; you betrayed me."

But the larger questions endure, and I suspect those obsolete HIV statutes will endure as well. AIDS is only one of hundreds of infections that can move from one person to another. Some travel through the air, like tuberculosis; some move by touch, like staph. The air we breathe and the hands we shake will never be safe, anymore than safe sex is entirely safe, and as long as we are fallible, litigious humans, some of us will head to court and cite hoary public-health law to satisfy that primitive little blame monster in our brains.

As for AIDS, though, the fact is that for most new infections, the language of culpability and blame simply no longer applies. As Dr. Wafaa El-Sadr, the MacArthur "genius"-award-winning AIDS expert at Columbia University, wrote with colleagues in The New England Journal of Medicine last month, new HIV infections are now increasingly concentrated in specific pockets in the United States. They move among the poorest of the poor, the disenfranchised and socially marginalized, where substandard education means no escape. In these places the prevalence of disease is so high ( Washington, D.C., has rates as high as some African countries) that simply living brings risk of infection.

In other words, if you are a woman in some ZIP codes, falling in love and getting married, with no sexual partner but your husband, puts you at risk for HIV. We see these women in our clinics, more and more of them, but you won't find them in court. Whom would they sue?